PROJECT SUMMARY/ABSTRACT Healthcare providers' face many challenges adhering to evidence-based guidelines, and this contributes to poor health outcomes for the >100,000 children hospitalized with asthma annually in the United States. Successful methods to promote providers' initial adoption of guidelines have been developed, but to date, little research has focused on methods to robustly sustain guideline adherence. Adherence commonly deteriorates after initial implementation resources are removed. This adversely impacts children with asthma, as >70% are cared for in general hospitals, where resources tend to be preferentially allocated to adult care. Pathways (succinct versions of guidelines that provide visual, step-by-step guidance for healthcare providers) improve quality of care for children hospitalized with asthma. Pathway implementation strategies (methods for promoting pathway implementation) have achieved short-term improvements in care of children in general hospitals. However, to reap maximum value from limited implementation resources, we must identify asthma pathway implementation strategies that promote sustained delivery of high-quality care for children in general hospitals. To achieve that objective, this proposal harnesses the ?positive deviance? approach, which asserts that identification and examination of higher- and lower-performing hospitals can facilitate the discovery and wide dissemination of strategies to improve care. Specific aim 1 will involve a secondary quantitative analysis of existing data. Multi- level regression models with an interrupted-time series approach will be used to identify hospital-level factors associated with sustainability and hospitals with higher and lower sustainability performance. Sustainability will be defined as maintenance of higher guideline adherence and higher quality of care at 2 years after pathway implementation (long-term benefit) without declines after implementation resources are removed. Outcomes will include length of stay (clinical outcome that reflects time to recovery) and use of metered-dose inhalers (guideline adherence). Specific aim 2 will study the higher- and lower-performing general hospitals identified in Aim 1 using qualitative, constant comparative methods. The ERIC Framework of implementation strategies will be used to develop a semi-structured interview guide for key personnel involved in pathway implementation. This analysis will identify pathway implementation strategies that promote sustainability and important contextual factors that influence their success. This mixed-methods approach will produce a multi-dimensional, comprehensive understanding of how general hospitals can promote sustained delivery of high-quality care for children with asthma. These findings will fill crucial gaps in our understanding of sustainability, enable general hospitals to more effectively target limited resources, and enable us to develop a comparative-effectiveness trial of sustainability interventions. Thus, these findings will have important positive impacts-- they will advance the science of clinical practice improvement, facilitate sustained use of evidence-based guidelines, and improve health care quality for children, an AHRQ priority population.